ID - Aortic Aneurysms and Dissections · aortic dissection, TEVAR failed to improve 2-year survival...
Transcript of ID - Aortic Aneurysms and Dissections · aortic dissection, TEVAR failed to improve 2-year survival...
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Management of Aortic Aneurysms &Management of Aortic Aneurysms & Aortic Dissections.
Miss Indu DeglurkarMiss Indu Deglurkar
Consultant Cardiothoracic Surgeon
University Hospital of Wales
Cardiff
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Aetiology of Ascending Aortic gy gAneurysms
Degenerative
BAV
Syndromic Syndromic
Marfans
Loeys- Dietz
Ehler- Danlos
Turner/Noonan
Familial
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Aetiology of Ascending Aortic Aetiology of Ascending Aortic Aneurysms
-
Infections: Syphilis
-Bacterial infections
Auto-immune arthritis Auto immune arthritis
Takayasu
B h t di Behçet disease
Idiopathic aortitis
Post-traumatic
Chronic aortic dissection
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Ascending Aortic AneurysmsAscending Aortic Aneurysms
Detection is essential because of the indolent nature & lethality of the disease.indolent nature & lethality of the disease.
Detection is difficult because thoracic aortic aneurysm is a silent disease – a ‘silent killer’silent killer
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Management of Ascending Aortic g gAneurysms
Medical TreatmentMedical TreatmentFollow-up by Imaging TechniquesFollow-up by Imaging TechniquesPredictors of complicationspSurgical treatment: IndicationsType of surgery
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Management of Ascending Aortic g gAneurysms: Medical Management
A i Aggressive blood pressure controlBeta blocker preferred
If contraindicated: ACEI/ARBsIf contraindicated: ACEI/ARBs
Follow-up of aortic size by close imaging techniques
N EngJ Med 1994 330.1335-1341
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BiomarkersBiomarkers
We need a biomarker to identify this asymptomatic, indolent & lethal diseaseindolent & lethal disease
‘RNA Signature’ blood test may be suitable for g yapplication to at-risk populations,
Sh ll t iti it d ifi it Shows excellent sensitivity and specificity,
Overall accuracy of 80% Overall accuracy of 80%
Distinguishes familial from non-familial aneurysms and ascending from descending aneurysms.
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Other BiomarkersOther Biomarkers
Matrix metalloproteinases
Inflammatory markers: CRP, CD4 count
Markers of collagen turnover: elastin peptidespeptides
Endothelins and hepatocyte growth p y gfactor
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Follow-up Imaging TechniquesFollow-up Imaging Techniques
Aortic root: Echo image of dilated aortic Aortic root:
2D-echo annually
groot
MRI aorta2D echo annually &
every 6m when the bsol te si e >45
o
absolute size >45mm for significant AR
Tubular AA: MRI and CT to Tubular AA: MRI and CT to evaluate the entire aorta
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Inherent level of resolution in current imaging technology
In clinical practice
Not significant change if <3-4mm
Frequent mistakes Frequent mistakes
-Not to use the same imaging technique
-Axial measurements may
exaggerate diameter in elongated ascending aorta
-Motion artefacts can adversely affect the resolution of CT images producing changes as great as 7.5% to 27.5%
Gated CT angiography-
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Mean Age & Size at gpresentation
Age Size
Hypertension 64.2yrs 60mm
Marfans 24 5yrs 51mmMarfans 24.5yrs 51mm
BAV 49yrs 52mmy
Loeys-Dietz 19.8yrs 40-50mm
Ehler Danlos No data No data
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Yearly risk of rupture, dissection or y p ,death related to thoracic aortic size
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Risk of aortic rupture related to pdiameter and BSA
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Risk of ruptureRisk of rupture
<4 cms 0%
4.0-5.9cms 16%
>6 31% >6 cms 31%
The one-, three-, and five-year survival of unoperated thoracic aneurysms was 65, 36, and 20 percent, respectively
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“Hinge points” for lifetime natural history complications at various sizes of history complications at various sizes of
aorta
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Aortic diameter >5.5cms is not a ood edicto of T e A Ao tic good predictor of Type A Aortic
DissectionDissection
Limited value of aortic size
<50mmsurgery would fail to prevent 40% of aortic dissection
Dilatation is only one manifestation of aortic wall disease
Circulation2007; 116:1120 Circulation2007; 116:1120
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Marfans vs BAVMarfans vs BAV
Marfans has a high lifetime grisk (40%) of aortic dissection
BAV disease carries a 6.1% life time risk of aortic dissection (9 fold higher than general population)
BAV is 100 times more common than Marfans
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S i l ith Tho cic A e s sSurvival with Thoracic Aneurysms
Elefteriades et al Radiology 199,211:889
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I dices fo o lisi di ete sIndices for normalising diameters
Aortic root diameter ratio Aortic root diameter ratio:
Observed/maximum predicted>1.3
AA area/height>10
AA diameter/BSA > 2.75 mm/cm2
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SurgerySurgery
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Indications for elective surgery g yin Ascending Aortic Aneurysm
Aortic diameter >55mm>55mm
Evaluate comorbidities
Risk of surgery
Age
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Indications for elective surgery in g ythe Bicuspid Aortic valve
Aortic diameter > 55mm Aortic diameter > 55mm
Aortic diameter> 50mm if: -Aortic coarctation
-First degree family relative with AoD/rupture
- Small body size:
Aortic diameter/BSA > 2.75cm/m2
- Severe AS or AR without surgical criteria
Expansion rate> 2mm/yr- Expansion rate> 2mm/yr
Aortic diameter > 45mm with concomitant indication for elective AVR
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Indications for elective surgery g yin Marfans syndrome
Ascending aortic diameter > 50mmg->45mm with risk factors
First degree with ascending aortic dissection/rupture-First degree with ascending aortic dissection/rupture.
-Concomitant indication for AV surgery
-Ratio of aortic diameter to BSA >2.75cm/m2
-Expansion rate > 2mm/yr
>40mm if pregnancy is desired and AV repair not required.repair not required.
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SurgerySurgery
Aortic root with a composite valved graft
Ascending aortic replacement/ hemiarch
Valve sparing root replacement.p g p
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A di & h i h l tAscending & hemiarch replacement
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ConclusionsConclusions
Although Marfan’s & BAV present wall abnormalities that cause aortic wall weakness and its progressive dilatation, the risk of p g ,dissection/rupture is higher in Marfans syndrome.
In patients with Marfans with risk factors surgery should be In patients with Marfans with risk factors, surgery should be considered when diameter is 45mm.
In BAV without severe dysfunction of the valve timing of In BAV, without severe dysfunction of the valve, timing of ascending aorta surgery( 50 vs 55mm) should be individualised considering the presence of aortic coarction, body size, progressive dilatation, age & comorbidities. With concomitant indication of AVR aortic surgery should be performed when diameter is >45mm diameter is >45mm
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HistoricallyHistorically
The first case of aortic dissection described was in the post-mortem examination of King George II of Great Britain in 1760.
Surgery for aortic dissection was introduced in the 1950s. Since DeBakey first reported his surgery for y p g yaneurysm the techniques have steadily advanced.
Since the 1990s Endovascular Repair has been used in Since the 1990s Endovascular Repair has been used in specific cases.
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Risk factors for aortic dissectionRisk factors for aortic dissection
Medial degeneration. Marfan syndrome,g y ,
Loeys-Dietz syndrome,
Vascular form of Ehlers-Danlos syndrome, inflammatory diseases of the aorta,
Turner’s syndrome,
Bicuspid aortic valve Bicuspid aortic valve,
Familial thoracic aortic aneurysm and dissection dsyndrome
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Risk factors for aortic dissectionRisk factors for aortic dissection
Increases wall stress: Hypertension
h h pheochromocytoma,
cocaine use
coarctation.
Physical trauma: weightlifting, deceleration injury in motor vehicle accidents
Smoking also increases dissection risk by affecting TGF-β.
Prior cardiac surgery
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ClassificationClassification
class 1 =Classic aortic dissection class 1 Classic aortic dissection
class 2= Intramural haematoma/haemorrhage
class 3= Subtle-discrete aortic dissection
class 4= Plaque rupture/ulceration class 4= Plaque rupture/ulceration
class 5=Traumatic/iatrogenic aortic dissection
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Operative indications for acute and pchronic Type A & B dissections
Acute Type A : Presence Acute Type A : Presence
Type B: Rupture, malperfusion, progressive dissection failure of medical managementdissection, failure of medical management
Chronic: type A: Symptoms related to dissection
- CCF, AR, pain, stroke, angina
- Type B: Symptoms, malperfusion, aneurysm.
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Controversies in management gof AoD
>80 f >80 yrs of age
Neurological injuriesNeurological injuries
Late presentationsLate presentations
Previous cardiac surgeryPrevious cardiac surgery
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5 tenets of Type A AoD repair
M di l t ti Myocardial protection
Cerebral protection Cerebral protection
Restoration of competent aortic valve
Excision of intimal tear site
Elimination of flow in false lumen blood flow and maintenance of true lumen blood flow
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Goals of repair of AoDGoals of repair of AoD
P i l f A D C t ith Primary goal of AoD: Come out with a live patient
Not to obliterate the false lumen!
Majority will have a patent false lumen
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O ti lt f A t T A/ BOperative results of Acute Type A/ B
Post operative mortality for Type A: 24%
5 yr survival: 55% - 75%
10 i l 32% 65% 10 yr survival: 32% - 65%
Post operative mortality for Type B: 28 – 65%p y yp
5 yr survival: 48%
10 yr survival: 28%
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Results of Chronic Type A/B yprepair
Post operative mortality for Chronic Type A: 10-17%%17%%
5 yr survival: 59% - 75%
10 yr survival: 45%
P t ti t lit f h i T B 11% Post operative mortality for chronic Type B: 11% -15%
5 yr survival: 48%
10 yr survival: 28% 10 yr survival: 28%
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Median diameter at time of rupture
Ascending aorta 5.9cms
Descending aorta 7.2cms
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Long-Term Survival in Patients Long Term Survival in Patients Presenting With Type B Acute Aortic Di iDissection
Thomas T. Tsai (Circulation. 2006;114:2226-2231.
242 consecutive patients discharged alive with acute type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003
Contemporary follow-up mortality in patients who survive to hospital discharge with acute p gtype B aortic dissection is high, approaching 1 in every 4 patients at 3 yearsin every 4 patients at 3 years.
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Endovascular Repair of Type B Aortic DissectionEndovascular Repair of Type B Aortic DissectionLong-Term Results of the Randomized Investigation of Stent Grafts in Aortic Dissection TrialStent Grafts in Aortic Dissection TrialChristoph A. Nienaber, MD, PhD, Stephan Kische, MD,Hervé Rousseau, MD, PhD,Holger Eggebrecht, MD, Tim C. Rehders, MD,Guenther Kundt, MD, PhD,Aenne Glass, MA,Dierk Scheinert, MD, PhD, Martin Czerny, MD, PhD,
il l i f ld kh i f l i b ll i Tilo Kleinfeldt, MD,Burkhart Zipfel, MD,Louis Labrousse, MD,Rossella Fattori, MD, PhD, Hüseyin Ince, MD, PhD,
TEVAR in addition to optimal medical treatment is associated with improved 5-year survival and delayed disease progression.
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Randomized Comparison of Strategies for Type B Aortic Dissection The INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) Trial
Christoph A et al
Circulation December 22/29, 2009
In the first randomized study on elective stent-graft In the first randomized study on elective stent graft placement in survivors of uncomplicated type B aortic dissection, TEVAR failed to improve 2-year aortic dissection, TEVAR failed to improve 2 year survival and adverse event rates despite favorable aortic remodelingaortic remodeling.
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E d l f l i Endovascular stent graft placement in thoracic aortic aneurysms and ydissectionsIssued: June 2005NICE
is a suitable alternative to surgery in is a suitable alternative to surgery in appropriately selected patients.
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Th k YThank You
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Pathophysiology of Aortic p y gyAneurysms
Mechanisms
-Congenital aortic fragility from genetic predisposition-Congenital aortic fragility from genetic predisposition
-Mechanical stress
Aortic media affected by damage and repair events
-Excessive injury: Valve dysfunction, hypertension, age
Impaired repair: Connective tissue disorders
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International Registry of Acute g yAortic Dissection (IRAD)2000
12 International referral centres 6 countries
Coordination centre at University of Michigan
A total of 464 patientsp
62.3% had type A dissection
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Common symptomsy p(IRAD)
Chest pain → 84.8%
Aortic regurgitation → 31.6%
Pulse Deficit → 15.1%
Hypertension → 70.1% (in type B)
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Diagnosis g(IRAD)
Chest X-Ray → No Abnormality in 12.4%
ECG → No Abnormality in 31.3%
CT Scan → used in 61.1% of cases
Echocardiography →used in 32.7%
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Outcome (IRAD) ( )Overall in hospital 27.4% Mortality
Type A
S (72% ) 26%Surgery (72% )→ 26%
Medical → 58% advanced age ,comorbidity
Type B
S rger (20%) 31 4%Surgery (20%) → 31.4%
Medical → 10.7%
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Cause of DeathCause of Death
Type A
A i d 41 6%Aortic rupture or tamponade → 41.6%
Visceral Ischemia → 13.9%
Type B
Aortic r pt re 38 5%Aortic rupture → 38.5%
Visceral Ischemia →15.4%
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Initial diagnostic steps in the g pemergency room
ECG must be acquired in all patients. 20% of patients with type A dissection have ECG evidence of acute ischaemia or ypacute myocardial infarction
The chest X-ray is not sufficient to rule out aortic dissection
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Guidelines for the Diagnosis and M t f P ti t With Management of Patients With Thoracic Aortic Disease
March 2010ACC/AHA Guideline
Class IClass I
Aortic imaging is recommended for first-degree relatives g g gof patients with thoracic aortic aneurysm and/or dissection to identify those with asymptomaticdisease.
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Initial ManagementInitial Management
Class I
Initial management of thoracic aortic dissection should be directed at decreasing aortic wall stress by controlling heart rate and blood pressurerate and blood pressure
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Management of haemodynamically unstable g y ypatients with suspected aortic dissection
RecommendationsRecommendations
1. Profound haemodynamic instability: intubation and ventilation I C
2. Transoesophageal echocardiography as the sole diagnostic procedure — IIC
3. Surgery-based on findings of cardiac tamponade by transthoracicechocardiography II C
4. Pericardiocentesis (lowers intrapericardial pressure (recurrent bleeding!) III C
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6.Reduction of systolic blood pressure using beta-blockers (i.v. propranolol, metoprolol, esmolol or labetalol) → IC
7. Transfer to intensive care unit → I C
8. In patients with severe hypertension additional vasodilator (i.v. sodium nitroprusside to titrate BP to 100–120 mmHg) → IC
9. In patients with obstructive pulmonary disease, blood pressure lowering with calcium channel blockers → IIC
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Long term survival type ALong-term survival type A
Surgically managed patients had a follow-up mortality of 13.9%, mean survival 2.5 years %, y
medically managed patients had a mortality of 36.7%, mean survival 2 1mean survival 2.1
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10. Imaging in patients with ECG signs of ischaemia before thrombolysis if aortic pathology is suspected → IICbefore thrombolysis if aortic pathology is suspected → IIC
11 Chest X ray → III C11. Chest X-ray → III C
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Cl Class I
A l di h ld b b i d ll i An electrocardiogram should be obtained on all patients who present with symptoms that may represent acute h i i di ithoracic aortic dissection
h l f h i h l i f ibl The role of chest x-ray in the evaluation of possible thoracic aortic disease should be directed by the
i ’ i k f dipatient’s pretest risk of disease
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Subsequent ManagementSubsequent Management
Class I
Acute thoracic aortic dissection involving theg
ascending aorta should be urgently evaluated for emergent surgical repair because of the high risk of associated life-surgical repair because of the high risk of associated lifethreatening complications such as rupture.
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Class I
For patients with ascending thoracic aortic dissection, all aneurysmal aorta and the proximal , y pextent of the dissection should be resected. A partially dissected aortic root may be repaired with p y y paortic valve resuspension.Extensive dissection of the aortic root should be treated with aortic root replacement with a composite graft or with a valve sparing root replacement. If a DeBakey Type II p g p y ypdissection is present, the entire dissected aorta should be replacedp
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Class IIa
It is reasonable to treat intramural hematoma similar to aortic dissection in the corresponding segment of the in the corresponding segment of the aorta
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Follow upFollow-up
Pathology Interval Study Study
Acute dissection Before discharge, 1, 6 mo, yearly CT orMR, TTE
Chronic dissection Before discharge, 1 y, 2 to3 y CT ,MR, TTE
Aortic root repair Before discharge, yearly TTE
AVR plus ascending Before discharge, yearly TTE
Aortic arch Before discharge, 1 y, 2 3 y CT ,MR, chest
Thoracic aortic stent Before discharge, 1, 2, 6 mo, yearly CXR,CT
Acute IMH/PAU Before discharge, 1, 3, 6 mo, yearly CT , MR
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Recommendations for Thoracic Ste t G ft I se tioStent Graft Insertion
1-Penetrating ulcer/intramural hematoma
Asymptomatic III
Symptomatic IIa
2-Acute traumatic I
3-Chronic traumatic IIa
4-Acute Type B dissection
Ischemia I
No ischemia IIb
5-Subacute dissection IIb
Chronic dissection IIb